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We’ve got some great objects on display in our new exhibition – spiders, an Xbox, an anaesthesia machine, and more. These help to bring the stories we’re telling in Pain Less to life.

But pain is personal, and that has driven how we are presenting the stories in our exhibition. The objects we’ve found give a tangible link to our stories, but we want to introduce our visitors to the people behind them.

So we tore ourselves away from our desks, hopped on trains, planes and auto-mobiles, and headed off around the country to film interviews with the scientists and people whose tales we’re telling in Pain Less.

These films make up a key part of the exhibition, and you might have noticed over the last few weeks they have been appearing on the blog, but in case you missed them here they are… Enjoy!

One of the things I’ve been doing is working with people from outside of the Museum. This group of adults who live with pain will give a different view on our content.

Over eight sessions they provided us with an insightful and personal perspective on our new exhibition. This significantly shaped our approach to the exhibition and the outcome of these creative workshops are on display as part of Pain Less.

So where did we start?

To start things off, we brought together several top researchers to give short talks about pain, anaesthesia and consciousness to our participants. This gave everyone the chance to find out more and talk directly to the researchers about the science behind the exhibition.

The first few sessions focused on getting to grips with the ever-changing content. With the help of our great facilitator, Lucinda Jarrett, it soon became clear that out of the three topics, pain really stood out as the most interesting and relevant to the group – in particular how pain is a very personal experience. This might seem obvious, but it was learning about the experiences of people living with chronic pain that really brought this home for us. It became an important part of the look and feel of the exhibition, which you’ll hopefully see really clearly when you come and visit.

In the sessions we explored the link between the brain and body when we feel pain – how did the group’s experiences compare with the findings of our researchers? Which research stories could they relate to?

We also needed to think about how was this going to appear within the exhibition. An open offer to do anything you want for an exhibition can be daunting… so we provided a few suggestions that we also knew we could support the group with.

After some consideration the group chose to make a film. This would explore a story or stories from the exhibition. The idea was to think about the scientific research and provide personal reflection on what the studies mean to people who live with pain every day.

The creative process

Before we could get the cameras rolling we needed a better idea of what this film was going to be, and how it would reflect the research covered in Pain Less. We recruited artists and film-makers Deborah Padfield and Helen Omand to work with the group in a series of workshops, and help shape their creative responses into a film.

The different members of the group had their own perspectives on the stories being told in the exhibition and their own ways of expressing this. They all chose some objects from the exhibition – and some that they brought themselves – and used them to create visual metaphors for what they wanted to express.

For one participant the idea of losing consciousness under anaesthesia wasn’t scary but actually a welcome relief from pain – so the anaesthesia machine was particularly interesting. Another person was fascinated by the research into using tarantula venom to relieve pain – we didn’t have the real thing at the time and so had to make do with a fake spider instead!

Once the visual metaphors had been photographed it was time to start filming. Deborah and Helen filmed the metaphors along with members of the group discussing the objects they had chosen, and the research stories told in the exhibition.

These discussions explored several perspectives on the content from the members of the group, such as the link between the brain and body, and the nerves which transmit pain, how pain can affect our mood and emotions, and how pain is a constant experience, but one that changes for various reasons. Another common theme was the individual ways in which everyone experienced pain and found their own ways to cope with it. Many participants also expressed hope that improved scientific understanding and medicine would lead to better pain relief in future.

Once the individual sequences of film were made the group got together with Deborah and Helen to watch the scenes and think about how they might link them together.

The group started off with a creative exercise using water, ink, string and sand to paint pictures that might represent links. In previous discussions, the idea of representing the link between nerves and the brain with threads, hairs and wires had come up a few times, so we looked at different ways of using this in the film. Poetry, reflections and shared thoughts from the sessions were also useful.

When the group reassembled for their final meeting, they viewed a rough-cut of the film, talked about a few edits and after some careful consideration chose a title:

Fragmented Lines: revisualising pain

All I can say now is a huge thank you to all the members of the group who dedicated their time to the sessions. The film is now installed in the exhibition and can be viewed in its own reflective space. Personally, I’ve found it inspiring to be able to meet such interesting people and I greatly appreciate the personal perspective they have given to the exhibition.

If you’ve ever had surgery, or simply had a tooth out, then you’ll know popping a couple of Ibuprofen just isn’t going to cut it, you want to be numb, or even better, unconscious… Enter the anaesthetists.

Medics have been using anaesthetic drugs for over 150 years and they have plenty of clinical evidence that they work extremely well. But how does anaesthetic actually work? And how much to we understand about what we experience when we lose consciousness?

During anaesthesia for major surgery, drugs prevent you being aware of painful sensations. Doctors often conduct minor surgery, and other procedures, under local anaesthesia, and use sedative drugs to calm you.

General anaesthetics and sedatives alter your state of consciousness. Anaesthetists commonly give them in combination with powerful painkillers to make sure your surgery is as painless as possible.

Today general anaesthesia often begins with an injected dose of the drug propofol. Researchers know a good deal about how this drug works on a cellular level.

‘Our cell research showed us that propofol influences receptors on certain nerve cells. These nerves normally respond to a chemical messenger called GABA that stops them sending signals. Propofol mimics the effects of GABA and inhibits nerve signals.’ says Jeffery L Barker from the Laboratory of Neurophysiology, part of the NINDS institute in Bethseda, Maryland

Propofol is only one of many different types of anaesthetic drugs. Each type appears to affect different sets of receptors in the brain, but they all make you lose consciousness.

Because some anaesthetic drugs influence different kinds of neuron compared with others, their precise effects on the brain may be very different.

Brain research tools can show which areas of the brain are affected by different anaesthetics. With fMRI (functional magnetic resonance imaging), for example, a scanner shows brain activity in 3D. On the other hand, when an EEG (electroencephalogram) is recorded, non-invasive electrodes are stuck onto your scalp to measure electrical activity on the brain surface.

EEGs and fMRIs can measure brain activity during different levels of consciousness: awake, asleep and even anaesthetised.

So what can today’s brain imaging technologies tell us about how anaesthetics work?

Steven Laureys leads the Coma Science Group at the University of Liège in Belgium. In an experiment he anaesthetised patients and scanned their brains.

‘Even when volunteers were unconscious, small “islands” in the sensory cortex of their brains showed activity in response to external stimuli,’ says Steven. ‘But this activity did not spread through the brain to areas that control behaviour and memory. This means that although your brain responds to sensations while you’re unconscious, memories don’t form as they would normally.’

Most people seem to have to no memories of sensations during surgery. But Jackie Andrade, Professor of Psychology at Plymouth University, has demonstrated that we’re able to form partial, ‘implicit’, memories under anaesthesia.

‘We tested patients by having them listen to certain words during surgery under general anaesthesia. When they came around, we found that the patients responded differently to words we had played while they were “unconscious” than to other words.’

There are two groups of patients with explicit memories of surgery: those who can remember pain and those who can’t. If you remember pain, you are much more likely to develop post-traumatic stress. But Jackie thinks that implicit memories may also affect you.

‘Although you’re not aware of these memories at all, they could affect recovery times after surgery and cause psychological stress.’

‘Implicit memory could be used to benefit patients undergoing surgery. Encouraging and positive comments made in the operating theatre could be used to reassure patients and reduce anxiety, even while they’re unconscious.’

So how can research improve future anaesthesia?… Do we just need better drugs?

Consultant anaesthetist Andrew Morley from St Thomas’ Hospital in London thinks new drugs are not the top priority.

‘Patients having surgery under anaesthesia in future will benefit more from small changes in all aspects of the process than from a single “miracle” anaesthetic drug,’ says Andrew.

‘Even if we don’t know exactly how they work, today’s general anaesthetics are highly effective. Before surgery, I consider both patient and planned operation in deciding the best combination of drugs and techniques. I aim to provide good operating conditions for the surgeon, minimising side effects and getting the best possible outcome for each patient. It’s a bespoke business.’

Could new technology be the answer?

The fEITER is a portable imaging technology that has successfully recorded 3D images from anaesthetised brains as they lose consciousness.

Brian Pollard, who developed fEITER the University of Manchester, explains:

‘These images gave us confirmation that losing consciousness involves changes in electrical activity deep inside the brain. Finding out about the process of anesthesia and sedation can help us monitor brain function in the operating theatre, and reduce the risk of painful awareness during surgery.’

But are high tech monitors alone enough to improve anaesthesia?

Emery Brown’s work at the Department of Anaesthesia, Massachusetts General Hospital and at the Department of Brain and Cognitive Sciences, MIT spans two disciplines: anaesthesia and neuroscience. He believes electroencephalogram (EEG) recordings allow anaesthetists to see when someone is unconscious and to understand how anaesthetic drugs create altered states.

‘Different drugs produce signatures that are readily interpretable using EEG. I can see signatures which indicate that the brain is unable to process information, which would mean that you are unconscious. In the future, we may be able to identify the brain circuits for consciousness and pain, and treat them directly using targeted drugs delivered to these circuits.’

Emery believes painful awareness can be prevented by training anaesthetists in neuroscience so they can interpret how EEG readings relate to underlying brain states.

‘The true culprit in cases of awareness is anaesthetists not being able to tell when a patient is unconscious. They often rely on brain activity monitors that are grossly simplified.

‘I can understand detailed raw EEG readings. If you came to me and told me you were afraid you were going to be aware during surgery, I would tell you that I can keep it from happening by keeping an eye on your EEG.’

It is clear to see experts are approaching this issue from all sides. But in the end it may all come down to the skilled experts in the operating theatre…

Andrew Morley explains, ‘Preventing painful awareness in surgery is not only about technology and understanding the brain.’ says Andrew Morley. ‘For decades, scientists and clinicians have tried to use the EEG – raw and otherwise – to distinguish conscious from unconscious patients reliably. No-one’s got it quite right yet – awareness still happens.’

‘Improving anaesthesia is also a matter of improving vigilance in the operating theatre and reducing the likelihood of human error. The Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland are gathering information on real cases of accidental awareness during general anaesthesia. The results may help us progress towards a better practice and healthier patients.’

Pain helps you minimise damage to your body by warning you when you’re hurt. Acute pain is caused by injuries, illnesses or surgery and tells your brain that something is wrong. Chronic pain, on the other hand, persists long after the cause has gone and your body should have healed. Every year the NHS spends £5 billion to treat chronic back pain alone.

Why is chronic pain so difficult to deal with?

If you take strong medication for a long time, it can become less effective and may cause unpleasant side effects, such as nausea or drowsiness.

Like any other chronic illness, chronic pain persists for a long time. It can be hard to find a cure and patients can endure a lifetime of suffering. Even though the pain seems to come from the body, ultimately it’s the brain that interprets the sensation of pain.

So how does your brain relate to your body when you feel pain?

Just like sight and touch, pain is part of your sensory system. Your senses provide you with vital information about the world around you. If you get your skin stuck in a zip, you’re able to react immediately.

A sensory map in your brain quickly tells you where the pain is. During your lifetime this map grows and changes in relation to your movements, sensations and even your injuries.

Can learning how the brain changes in relation to lasting pain lead to more effective relief?

For the first time, researchers at Northwestern University in Chicago have seen a change in grey matter in chronic pain patients. Scientists hope to understand the mechanisms that cause this change and use the knowledge to develop new therapies for chronic pain.

One particular type of chronic pain has already helped researchers understand more about how the brain changes in relation to serious injury – phantom limb pain.

If you suffer a serious injury such as an amputation, your brain’s sensory map no longer matches what you see or do. This happens because every adult brain has neuroplasticity – the potential to remould. About 60–80% of amputees develop pain in their missing limb. Sometimes the sensations can be as simple and strange as the feeling of a hand brushing their cheek. Other times it is persistent and hard to treat. Using mirrors or more complex virtual-reality games can help some people.

Scientists think the reason why virtual-reality games can reduce chronic pain is because of the adult brain’s ability to change. But could we use these treatments more effectively in future?

‘Our research has shown that virtual reality can reduce pain for hours, but we know little of its long-term effectiveness,’ says Jonathan Cole, a consultant in clinical neurophysiology at Poole Hospital and Bournemouth University. ‘What we really want to do is teach people to do this as soon as they lose their limb. The longer you wait, the more time the brain has had to grow the wrong connections and reinforce the pain.’

‘Because the adult brain is dynamic and changes throughout our life, it’s certainly possible that in future virtual-reality techniques could be extended to treating other common pain problems, such as certain types of back pain. However, virtual reality doesn’t always work for everyone,’ says Ilan Lieberman, a pain consultant at Spire Manchester Hospital.

So is there an overarching solution to chronic pain?

‘Over the past 50 years, people have been looking for a one-size-fits-all treatment for chronic pain,’ says Vania Apkarian, a leading chronic pain researcher at Northwestern University. Vania thinks treatments in the future will be tailored to the individual.

‘With today’s advances in brain imaging, we can see that the brain of every chronic pain patient is structurally and psychologically different. We found that there are different forms of chronic pain, each with their unique brain imprint. You can’t expect to treat them all in the same way.’

In an ideal future, doctors would be able to use medical scans to look into the brain of a patient and see exactly where things have gone wrong.

This level of insight is what Vania’s research team are trying to achieve.

‘We’re entering into unknown territories, testing drugs that may reveal brain areas involved in chronic back pain. I can’t disclose more for now, but if successful, it will provide evidence that understanding brain mechanisms of chronic pain can lead to targeted therapies.’

You might not like it, but you need to feel pain. It’s important. It helps to keep you safe by letting you know when something is wrong. You experience pain through specialised nerve cell endings called nociceptors. You will find these throughout your body, but some areas, such as your skin, have more than others. They alert you to different causes of pain which could harm you, such as extreme temperatures, pressure, damaging chemicals and infection.

So how does a painful sensation tell your brain you’re in trouble?

You accidently put your hand on a hot hob… ouch! Your nociceptors respond to this pain and create an electrical signal using special proteins called sodium channels. These channels are like gates in the membrane that surrounds the nerve cell. When a cause of pain – such as hand on hob – triggers a signal, these gates open and let in a flood of positively charged sodium ions. This changes the electrical charge of the nerve and a signal travels from nerve to nerve, up the spinal cord and into your brain to alert it to the pain.

We have nine different types of sodium channels, but only one is particularly important for pain – Nav 1.7. This channel is essential to transmit pain signals. Each channel has its own gene, which provides the instructions for how the channel should work. The gene for channel Nav 1.7 is called SCN9A. Mutations to this gene effect how you experience pain. Some mutations can make people super-sensitive to pain, while other mutations can cause people to feel no physical pain at all.

A rare mutation to the SCN9A gene, called a non-sense mutation, causes the sodium channel to stop working. This means that pain signals from the body aren’t transmitted to the brain. People with this genetic mutation are unable to feel any physical pain and can’t smell, but are otherwise healthy. Fewer than one in a million people in the UK can’t feel pain because of SCN9A mutations.

Researchers want to recreate the effect of the mutation to treat pain in others. If scientists can isolate a molecule that can block pain signals in the same way they will have a powerful painkiller.

Oddly enough research reveals that molecules in toxic venom from snails, snakes, scorpions and spiders can block human sodium channels. If scientists can find the venom component that only blocks pain channel Nav 1.7 it could mean pain relief without serious side-effects. This is because Nav 1.7 is only responsible for pain and smell, unlike other targets for pain-relief drugs, such as opioid receptors. As well as pain relief your opioid receptors are linked to your emotions, and things you do automatically such as breathing.

A drug which only targets Nav 1.7 would specifically target the experience of pain.

Could venom be the ‘wonder drug’ of the future?

‘Yes!’ says Pierre Escoubas, Founder of Venome Tech.

‘Your nerves have many sodium channels to communicate between the brain and body. Each has a specific function. Blocking a channel other than pain channel Nav 1.7 could have serious effects on the heart, muscles or nervous system. A treatment with too general a target could be fatal.’

‘Venom-derived molecules can be very selective. This makes them the ‘magic bullet’ of potential drugs, as they hit a specific target without undesirable side effects.’

Venom might be the source of a future drug for pain relief. But it’s not as easy as just milking a spider…

‘The big problem is that the peptides (protein parts) we have isolated so far are not selective enough. They strongly block Nav 1.7 but they block other channels as well’ explains Glenn King, Professor of Molecular Bioscience at the University of Queensland.

‘Right now we have found a good candidate which is very effective at blocking Nav 1.7. Unfortunately it also blocks Nav 1.6, which might cause undesired side-effects. So, we’re hoping to tweak the molecular structure a little and get the selectivity required for a perfect painkiller.’

Could this pain killer be too effective?

Pain may not be pleasant but it helps keep you from hurting yourself too. If the drug blocks all pain could it be so good it’s bad?

’I think we would only need to worry about a drug this effective being too good if the effects were permanent’ says Glenn King. ‘The molecules we’re looking at have a limited life in the bloodstream and eventually break down. Patients would probably need regular top-ups.’

Venom has a lot of potential, but it’s not the only possible future for pain relief.

‘Another type of pain transmitter in the body is the transient receptor potential (TRP) channels’ explains Julie Keeble, a pharmaceutical researcher at Kings College London.

‘As part of my research I have been studying the role of TRP channels in painful inflammation, such as the chronic pain associated with arthritis. Some TRP channels are affected by simple kitchen ingredients – like hot chilli peppers and mustard oil, but they can also be activated by chemicals that are produced during pain. Drugs to target these channels are still progressing through clinical trials, but they may offer new hope for chronic pain patients.’

You don’t just experience pain physically. The amount of pain you perceive is influenced by environmental factors – for example sound, temperature and your surroundings – and psychological factors, such as your thoughts, beliefs, feelings and attitudes.

Your expectations and emotions are powerful. They can have a significant impact on the success of a treatment. You might experience pain relief, or improved symptoms, from taking fake medication or having a fake procedure. This is known as the placebo effect.

In one experiment led by psychologists at the University of Michigan, participants received a placebo that they were told would help reduce pain from painful stimuli such as heat or an electric shock. Images of their brains while in pain showed less activity in the pain-sensitive areas of their brains when they had the placebo, compared with when they didn’t.

If positive expectations can make pain better, can negative thoughts make it worse?

The nocebo effect

Meet the placebo effect’s evil twin! Researchers have found that expecting negative side effects from drugs can sometimes be enough to cause them, even when the drugs are supposedly harmless. This is called the nocebo effect. In one experiment, a group of patients with back pain were asked to do a test. The half that was told it would make their pain worse reported that they experienced more pain.

So how might this change how medics talk about pain and pain relief?

The placebo and nocebo effects have shown the importance of the way you talk about pain. If doctors give negative suggestions, or tell patients too much information about possible side effects, they could increase the chance of the patient experiencing them.

‘Patients who have unrealistically high or very low expectations from a treatment may affect the efficiency of the drug or surgery they are having’ explains Paul Enck, Professor of Medical Psychology at University Hospital Tübingen.

’Probably the best way to address this in future is to speak to the patient about their expectations from the treatment. Choosing the right terms to use may be as important as avoiding giving the wrong information.’

Now we know that our thoughts and expectations can affect our response to pain treatment, can we actively change our emotions to make drugs more effective? And can understanding the effect of a good mood on your pain improve treatments?

‘If we can understand how being in a happy mood, or having positive expectations, reduces pain signals in the brain, we might be able to provide a radically different way to switch off the pain and provide relief,’ explains Irene Tracey, Director of the Oxford Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB).

But can patients find their own path to pain relief?

‘We have found that even a brief amount of meditation training can make a difference in the experience of pain,’ says Fadel Zeidan from Wake Forest School of Medicine.

‘In one of my experiments healthy volunteers were given a painful stimulus and rated their experience. After four sessions of meditation training, meditating whilst experiencing the painful stimulation reduced pain unpleasantness by 57% and pain intensity by 40%. In contrast, researchers have found that a clinical dose of morphine reduces pain by up to 25%.

‘Clinicians are already using meditation alongside medication to help reduce the amount of drugs patients need to take.’

‘Meditation is not necessarily about reducing the pain sensation, but about changing the perception of pain and relating to it differently,’ says Tim Gard at Massachusetts General Hospital, Harvard Medical School.

‘In one study I used brain imaging to see changes in the brain while meditating and experiencing pain. I found that activity in the brain was different between those who had and had not meditated before. The experience of pain was less unpleasant in those who meditated.

‘I think meditation will play an increasingly important role in chronic pain management, but alongside medicine rather than replacing it completely.’

So the question is; can we really have a drug free future?

‘For something like pain, in particular chronic pain, there is no doubt that a three-way approach – drugs, working with psychologists and physical rehabilitation – is the most successful,’ says Irene Tracey.

‘Pain is both a sensory and emotional experience. A single approach to tackle one element can provide a lot of benefits, but a combined approach really attacks the problem at all the different points at which pain can take hold.’

Future clinicians will need to decide who will benefit most from which combination of approaches. Which approach would you prefer?